Subsequent Cervical Disc Herniation following Single-Level ACDF

Preoperative laryngoscopic examination in patients undergoing repeat anterior cervical discectomy and fusion

Thursday, September 27, 2018 3:35 PM–5:05 PM Section on Motion Technology Abstract Presentations: 132. Subsequent cervical spine surgery after cervical disc arthroplasty and anterior cervical discectomy and fusion

Retrospective cohort study. To compare short-term morbidity for primary and revision anterior cervical discectomy and fusion (ACDF). Revision ACDF procedures are relatively common, yet their risks are poorly characterized in the literature. There is a need to assess the relative risk of revision ACDF procedures compared with primary surgery. The prospectively collected American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was used to identify patients who underwent primary and revision ACDF from 2005 to 2014. The occurrence of 30-day postoperative complications, readmission, operative time, and postoperative length of stay were compared between primary and revision procedures using multivariate regression to control for patient and operative characteristics. A total of 20,383 ACDF procedures were identified, 1219 (6.0%) of which were revision cases. On multivariate analysis, revision procedures were associated with significantly increased risk of any adverse event (relative risk [RR] 2.3, P < 0.001), any severe adverse event (RR 2.2, P < 0.001), thromboembolic events (RR 3.3, P = 0.001), surgical site infections (RR 3.2, P < 0.001), return to the operating room (RR 1.9, P = 0.001), any minor adverse event (RR 2.5, P < 0.001), and blood transfusion (RR 8.3, P < 0.001). Revision procedures had significantly increased risk of readmission within 30 days (RR = 1.6, P = 0.001). Minor, but statistically significant increases in average operative time and postoperative length of stay were identified for revisions procedures (7 min and half a day, respectively [P < 0.001 for both]). Revision procedures were associated with significantly increased risk of multiple adverse outcomes, including thromboembolic events, surgical site infections, return to the operating room, blood transfusion, and readmission within 30 days. These results are important for patient counseling and risk stratification. 3.

Systematic literature review. To analyze the literature and describe the evidence supporting osteobiologic use in revision anterior cervical discectomy and fusion (ACDF) surgery. A systematic search of PubMed/MEDLINE, EMBASE, Cochrane library, and ClinicalTrials.gov databases was conducted for literature reporting the use of osteobiologics in revision ACDF. We searched for studies reporting outcomes of using any osteobiologic use in revision ACDF surgeries (independently of the number of levels) in the above databases. There are currently no studies in the literature describing the outcome and comparative efficacy of diverse osteobiologic agents in the context of revision ACDF surgery. A majority of the current evidence is based only upon studies involving primary ACDF surgery. The current study highlights the paucity of literature evidence on the role of diverse osteobiologics in revision ACDF, and foregrounds the need for high-quality evidence on this subject.

P121. Chronic opioid use following anterior cervical discectomy and fusion surgery for degenerative cervical pathology

Retrospective cohort study. Evaluate the impact of increasing levels of cervical fusion on alignment and outcomes. One-level anterior cervical discectomy and fusion (ACDF) adequately restores cervical alignment and offers favorable postoperative outcomes. However, comparative studies following increasing levels of fusion are lacking. Patients who underwent one- to three-level ACDFs were identified. Demographics, spinopelvic alignment, and clinical outcomes were compared up to one-year postoperatively. Multivariate regressions, accounting for age, gender, Charlson Comorbidity Index (CCI), osteoporosis, and baseline cervical deformity were performed to examine the association between levels of ACDF and postoperative outcomes. Cox regression analysis was also performed to evaluate the association between levels of ACDF and time to reoperation. Among 279 patients (mean age 54.1years, 49% female, mean CCI 0.6), 110 had one-level, 137 had two-level, and 32 had three-level ACDFs. Perioperatively, estimated blood loss (19.1 vs 25.3 vs 33.8mL) was comparable and procedure time (131.2 vs 167.9 vs 225.9mL) increased with increasing levels of ACDF, with regression analysis revealing higher odds of both in three-level ACDFs (P<0.05). Postoperatively, instrument failure (1% vs 4% vs 13%, P=0.008) and cage subsidence (15% vs 28% vs 44%, P=0.001) rates increased with increasing levels of ACDF, with regression analysis showing higher odds of both in three-level ACDFs (P<0.05). Cox regression revealed a hazards ratio of 1.2 (95%CI=0.5-3.3) for two-level ACDF and 25.9 (95%CI=2.8-239.8) for three-level ACDF in predicting time to reoperation relative to one-level ACDF. Lordotic correction and improvement in PROMs were comparable across cohorts (P>0.05). Multi-level ACDF yielded comparable improvements in sagittal cervical alignment and PROMs, but was associated with worse in-hospital and out-of-hospital outcomes than single-level ACDF. In addition, it lowered the time to reoperation following the initial procedure. Surgeons should, thus, carefully select operative levels based on clinical and radiographic factors. IV.

To conduct a meta-analysis to assess dysphagia complicating single-level and multiple-level (≥2) anterior cervical discectomy and fusion (ACDF) surgery. Electronic searches were performed using four electronic databases from their inception to December 2017. Relevant studies reporting the rate of dysphagia as an endpoint for patients undergoing ACDF for degenerative disease, myelopathy, cervical canal stenosis or ossification of the posterior longitudinal ligament were identified according to prior inclusion and exclusion criteria. Statistical analysis was performed using a fixed effect model. P-scores were used to rank the levels of ACDF based on the rate of dysphagia. I2 was used to explore heterogeneity. Ten studies were identified and included in the systematic review and meta-analysis, with a total of 4,018 patients identified; 2,362 patients underwent single-level ACDF, while 1,656 underwent multiple level (≥2 ACDF). The mean age ranged from 49.45 to 57.77 years. Mean follow-up time ranged from 2 days to 27.3 months. Overall, meta-analysis demonstrated a statistically significant higher dysphagia rate for multiple-level ACDF (6.6%) than for single-level ACDF (4%) (P heterogeneity =0.151, OR =1.42, 95% CI: 1.05-1.91, I2=32%). Dysphagia is a relatively common complication in the early postoperative period following ACDF and may cause patients significant discomfort and distress. This meta-analysis demonstrates a higher rate of dysphagia with multiple-level ACDF than with single-level ACDF at a period of 12-24 months.

206. Additional surgery after anterior cervical discectomy and fusion versus posterior foraminotomy for single- or multilevel cervical radiculopathy

IntroductionCompared to anterior cervical discectomy and fusion (ACDF), the motion preservation of cervical disc arthroplasty (CDA) provides an attractive alternative with similar short-term results. However, there is a paucity of the economics of performing CDA over ACDF.Study Design:This was retrospective study.Objective:The objective of this study is to evaluate relative-value-units (RVUs), operative time, and RVUs-per-minute between single-level ACDF and CDA. Secondary outcomes included 30-day readmission, reoperation, and morbidity.Methods:Adults who underwent ACDF or CDA in 2011–2019 National Surgical Quality Improvement Program database datasets. Multivariate quantile regression was utilized.Results:There were 26,595 patients (2024 CDA). ACDF patients were older, more likely to be female, discharged to inpatient rehabilitation, and have a history of obesity, smoking, diabetes, steroid use, and the American Society of Anesthesiologists-class ≥3. ACDF had greater median RVUs-per-case (41.2 vs. 24.1) and RVUs-per-minute (0.36 vs. 0.27), despite greater operative-time (109 min vs. 92 min) (P < 0.001). ACDF predicted a 16.9 unit increase in median RVUs per case (P < 0.001, confidence interval [CI]95: 16.3–17.5), an 8.81 min increase in median operative time per case (P < 0.001, CI95: 5.69–11.9), and 0.119 unit increase in median RVUs-per-minute (P < 0.001, CI95: 0.108–0.130). ACDF was associated with greater unadjusted rates of readmission (3.2% vs. 1.4%) morbidity (2.3% vs. 1.1%) (P < 0.001), but similar rates of reoperation (1.3% vs. 0.8%, P = 0.080). After adjusting for significant patient-related and procedural factors, readmission (odds ratio [OR] = 0.695, P = 0.130, CI95: 0.434–1.113) and morbidity (OR = 1.102, P = 0.688, CI95: 0.685–1.773) was similar between ACDF and CDA.Conclusions:Median RVUs-per-minute increased by 0.119 points for ACDF over CDA, or $257.7/h for each additional-hour of surgery. Adjusted 30-day outcomes were similar between procedures. Reimbursement for CDA does not appear to be in line with ACDF and may be a barrier to widespread usage.

Anterior cervical discectomy and fusion (ACDF) is a surgical procedure used to manage spine pathology including disc herniation, spondylosis, and myelopathy. During the operation, the vertebral segment of interest is accessed via the anterior neck and the disc space is fully resected along with osteophytes to relieve the compression along the affected nerve. While the procedure is regarded as being highly effective in improving symptoms, there are several complications associated with the surgery that patients should be cautioned about. We present a case of a patient with oropharyngeal and cervical esophageal dysphagia and left vocal cord paralysis following a C5/C6, C6/C7, and C7/T1 ACDF for multilevel cervical stenosis and disc herniation. Otolaryngology evaluation confirmed vocal cord paralysis from recurrent laryngeal nerve palsy (RLNP) and the patient's symptoms were managed with a vocal cord injection and speech therapy. This report explores the surgical approach for ACDF along with its complications and postoperative care.

Retrospective cohort. We investigated whether postoperative physical therapy (PT) significantly reduces the risk and amount of oral opioid prescriptions in the first year after primary anterior cervical discectomy and fusion (ACDF) and the risk of any opioid prescription/administration. There is a need for nonopioid pain management strategies following ACDF in light of the opioid epidemic. We utilized deidentified medical records from the TriNetX network to identify opioid-naïve adults undergoing their first ACDF from 2014 to 2023. Patients were divided into cohorts by the presence or absence of postoperative PT (≤2mo post-ACDF) and propensity matched for variables related to opioid prescription. Primary outcomes were risk ratio (RR) and the mean number of oral opioid prescriptions in the first postoperative year. Secondary outcomes included the cumulative incidence and risk of any opioid prescription/administration. Each cohort had 4864 patients after propensity matching. Patients receiving PT had a significantly lower risk of oral opioid prescription in the first year after primary ACDF compared with patients not receiving PT [RR: 0.739 (0.714, 0.765); 48.8% vs. 66.1%; P<0.0001]. Patients receiving PT had a statistically significant lower risk of any-route opioid prescription in the first year after primary ACDF as compared with patients who did not receive PT [RR: 0.801 (0.782, 0.821); 65.7% vs. 82.0%; P<0.0001]. In addition, the mean instances of prescriptions per patient were lower for oral opioids (1.9 vs. 2.2; P=0.006) and any-route opioids (2.8 vs. 3.1; P=0.004) among patients receiving PT versus patients not receiving PT within 2 months. Postoperative PT is associated with significantly lowered risk and mean opioid prescriptions in the first year after primary ACDF. Further investigation is needed to understand PT's role in reducing opioid use. Level II.

155. Dual role of neck disability index in assessment of quality of life in cervical spine patients

Study DesignRetrospective Cohort.ObjectiveThis study aims to assess the easily measurable radiographic landmarks of screw-to-vertebral body ratio and changes in screw angle to identify if they are associated with early subsidence following an Anterior cervical discectomy and fusion (ACDF).MethodsA retrospective cohort study was conducted on patients undergoing 1-3 level ACDF with allograft or PEEK cages. Preoperative, immediate postoperative, and 6-month postoperative radiographs were analyzed to measure intradiscal height (or distance between 2 vertebral bodies) as an anterior vertebral distance (AVD), middle (MVD), and posterior (PVD), screw angle, screw-to-vertebral body length ratio, and interscrew distance. Multivariate stepwise regression analyses were performed.Results92 patients were included (42 single-level, 32 two-level, and 18 3-level ACDFs). In single-level ACDFs, a decrease in the caudal screw angle was associated with a decrease in AVD (=.001) and MVD (P = .03). A decrease in the PVD was associated with a decrease in segmental lordosis (P < .001). For two-level ACDFs, a higher caudal screw-to-body ratio was associated with a lower MVD (P = .01).ConclusionSix months following an ACDF for degenerative pathology, a decrease in the caudal screw angle was associated with an increase in radiographic subsidence at the antero-medial aspect of the disc space albeit largely subclinical. This suggests that the caudal screw angle change may serve as a reliable radiographic marker for early radiographic subsidence. Furthermore, a greater screw-to-vertebral body ratio may be protective against radiographic subsidence in two-level ACDF procedures.

The authors reviewed clinical and radiographic outcomes in patients who had undergone anterior cervical discectomy and fusion (ACDF) involving the placement of polyetheretherketone (PEEK) spacers filled with recombinant human bone morphogenetic protein (rhBMP)-2. Data obtained in 24 cases were retrospectively evaluated. The follow-up period ranged from 12 to 16 months (mean 13 months). Fifteen patients presented with radiculopathy, eight with myeloradiculopathy, and one with quadriparesis. Single-level ACDF was performed in 12 patients, two-level ACDF in nine, and three-level ACDF in three. Clinical outcomes were assessed using Odom criteria, and fusion was assessed by examining flexion-extension radiographs and computerized tomography scans in cases in which arthrodesis was questionable. Follow-up data were available for 23 patients. One patient died of medical complications unrelated to surgery 4 weeks after ACDF. Clinical outcomes were rated as good/excellent in 22 patients (95%) and fair in one (5%). Solid radiographically documented fusion, with evidence of solid bridging bone and no instability on flexion-extension x-ray films, was present in all cases. Complications included transient recurrent laryngeal nerve injury in one case, transient C-5 paresis in one, cerebrospinal fluid leakage in one, and transient dysphagia in two. Analysis of the results indicated that ACDF involving an rhBMP-2-filled PEEK spacer leads to good clinical outcomes (by Odum criteria) and solid fusion (even in multilevel cases) while avoiding the complications associated with harvesting iliac crest bone grafts.

50. Re-emergence of depressive symptoms and associated risk factors in cervical spine patients